Background: Based on multiple randomized controlled trials, expert guidelines have recommended use of hypofractionated whole breast irradiation (HF-WBI) for select patients with early-stage breast cancer. Compared to conventional regimens, HF-WBI has been found to be equivalent for local control and overall survival, and superior for toxicity, patient adherence and well-being. Despite compelling evidence and guidelines, adoption of HF-WBI as the preferred approach has lagged. To close this gap for patients covered by a large, regional Medicaid plan, Neighborhood Health Plan of Rhode Island (Neighborhood), implementation of clinical pathways and prospective peer review was put in place. Methods: This was a retrospective observational study using radiation oncology prior authorization data from Neighborhood in the New Century Health (NCH) database. NCH is a national specialty management company that supports over 100,000 unique oncology patients each year. As part of a risk-based relationship between NCH and Neighborhood, clinical pathways were put in place for oncology including mandatory use of HF-WBI for eligible patients. The pathways were embedded in the electronic prior authorization portal as clinical decision support and acceptance of hypofractionation led to automatic approval of request. Deviation from or clinical exceptions to use of WF-WBI led to real-time peer review by a radiation oncologist prior to approval. All practices in the Neighborhood network were included in the intervention. Results: 190 patients with breast cancer eligible for HF-WBI were tracked from September 2020 through July 2022. Use of HF-WBI was defined as a provider indicating intent to treat a patient with 16-21 fractions. At the start of the program, baseline HF-WBI use was 40% (17/43). At the end of 2021, HF-WBI use had meaningfully improved to 54% (50/93) and performance continued to rise to 61% (33/54) from January to July of 2022. Conclusions: Despite improved patient experience and guideline endorsement for HF-WBI for patients with early-stage breast cancer, adoption in the United States has lagged. Prior studies have shown that clinical pathways mandating use of HF-WBI, and prospective peer review can improve compliance with guidelines. Neighborhood and NCH combined both interventions with success, accelerating and sustaining adherence to evidence-based guidelines on hypofractionation for a network of 21 radiation oncology providers across 9 practices.